ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A healthcare professional is caring for a client with impaired mobility. Which of the following support devices should the healthcare professional plan to use to prevent the client from developing plantar flexion contractures?
- A. Sheepskin heel pad
- B. Footboard
- C. Trochanter roll
- D. Abduction pillow
Correct answer: B
Rationale: A footboard is the correct choice to prevent plantar flexion contractures by maintaining proper alignment of the feet. Plantar flexion contractures involve the foot pointing downward, and a footboard helps keep the foot in a neutral position. Choice A, the sheepskin heel pad, is used for pressure ulcer prevention and comfort but does not specifically address plantar flexion contractures. Choice C, the trochanter roll, is used for hip positioning, not foot alignment. Choice D, the abduction pillow, is used to maintain proper positioning of the legs but does not directly address plantar flexion contractures.
2. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?
- A. Contact the stoma nurse immediately.
- B. Educate the client on stoma care.
- C. Assess the stoma site for complications.
- D. Arrange for follow-up visits with the stoma nurse.
Correct answer: B
Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.
3. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding indicates the condition is worsening?
- A. Increased shortness of breath
- B. Decreased wheezing
- C. Productive cough with green sputum
- D. Slight increase in fatigue
Correct answer: A
Rationale: The correct answer is A: Increased shortness of breath. In COPD, worsening symptoms often include increased shortness of breath due to impaired lung function. This indicates a decline in respiratory status and the need for prompt intervention. Choice B, decreased wheezing, is not indicative of worsening COPD as it could suggest better airflow. Choice C, productive cough with green sputum, may indicate an infection but not necessarily worsening COPD. Choice D, a slight increase in fatigue, is non-specific and may not directly correlate with the worsening of COPD.
4. A nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?
- A. Hospice care
- B. Meals on Wheels
- C. Home health services
- D. American Association of Retired Persons
Correct answer: B
Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.
5. A nurse is teaching a client who has a new prescription for digoxin. Which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?
- A. Increased appetite
- B. Rash on the face
- C. Yellow-tinged vision
- D. Weight gain
Correct answer: C
Rationale: The correct answer is C: 'Yellow-tinged vision.' Yellow-tinged vision is a characteristic sign of digoxin toxicity, indicating an overdose of the medication. This visual disturbance is a critical adverse effect that should be reported promptly to the healthcare provider to prevent serious complications.\n\nChoice A, 'Increased appetite,' is not typically associated with digoxin use and is not a common adverse effect.\n\nChoice B, 'Rash on the face,' is also not a common adverse effect of digoxin. Skin rash is not a typical manifestation of digoxin toxicity.\n\nChoice D, 'Weight gain,' is not a common adverse effect of digoxin. Weight gain is not a typical symptom of digoxin toxicity and is unlikely to be related to the medication.
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